Will Obamacare create a two-tiered healthcare system?

Writing in the Wall Street Journal, John C. Goodman argues that Obamacare will inevitably lead to a two-tiered healthcare system. He correctly points out that the shortage of primary care doctors combined with increased insurance coverage may overwhelm our current system. Then he veers off the tracks.

Goodman argues that as patients find it harder to get an appointment with their PCPs (who will be busy providing newly-mandated preventative care), they will find other routes to get care such as emergency departments. What does he think our current system does?

Our healthcare system, with its millions of uninsured, drives people with trivial ailments and those with serious ailments not properly treated right to the hospital. The obvious solution seems to be to increase insurance coverage. Goodman argues that this will send a different group of people to ERs: people who can’t get an appointment because the previously-uninsured are filling the appointment book. Is this worse than our current system? Better? Simply different?

The other access problem he comments on is that of income disparity. As doctors become overwhelmed with patients, many, he says, will switch to “concierge” practices, taking a limited number of patients and charging yearly “retainers”. This, Goodman points out, will create a two-tier system of health care.

What he fails to point out is that we already have a two-tiered system. The uninsured don’t have the same care or the same choices as the insured who are usually employed or on Medicare, or have the money to purchase insurance privately. Millions go without for economic reasons alone. If the shortage of primary care doctors continues, we may indeed have a two-tiered system, one that is slightly more egalitarian than the current one. Concierge practices work in very specific environments, with high concentrations of wealthy people. These practices haven’t caught on widely.

The solution to this “crunch” isn’t to deny citizens coverage; it is to help increase the number of primary care providers. This will mean subsidizing medical education so that new doctors can afford to choose primary care. This will mean training mid-level providers such as nurse practitioners and physician assistants to do more primary care work.

Obamacare is far from perfect, but it will help democratize health care. If it really does create an immediate crunch in primary care, then all Americans will find what many already know—healthcare has never been a right in this country, but a privilege granted to those who can afford it. This may lead to real, systemic change.

1 Comment

Old Geezer

The very benefits of “Obamacare” that you write about are what Mr. Goodman and the audience for whom he writes find so disturbing. It democratizes health care. It gives the great unwashed “them” the same benefits that have heretofore been reserved to the elite “Us.” They can’t come right out and say this, so they bring up the straw man of two-tiered health care never realizing that such a thing exists now for the majority of those of us who are not among their elite. I pity their myopia.